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2 Payers differ on their guidelines. Please verify coding for each payer and claim. All Medicare and RAC information is literally changing on a daily basis. What is presented herein may or may not be valid for This is not legal or payment advice. This content is abbreviated for Medical Oncology. It does not substitute for a thorough review of code books, regulations, and Carrier guidance. This information is good for the date of the information and may contain typographical errors. CPT is the trademark for the American Medical Association. All Rights Reserved.

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4 Payments are based on RVUs for each code (WRVUs+PERVUs+MalRVUs) The pool of RVUs is fixed – any changes must be budget neutral--we had one of the few exceptions in RVUs are multiplied times GPCIs for your area. The 1.00 GPCI Floor has been eliminated. The Medicare conversion factor determines the overall level of Medicare payments A formula spelled out in the Medicare statute determines the annual update to the conversion factor and that has been a disaster.

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5 On March 4 th, the president signed H.R. 4691, the Temporary Extension Act of 2010 into law. This legislation includes a provision that freezes Medicare physician payments at their current level until March 31, The legislation also extends the therapy cap exception process through until March 31, The bill passed the Senate by a vote of 78 – 19. The House of Representatives had unanimously approved a companion bill by voice vote on Feb. 25. H.R The Senate debated H.R the American Workers, State, and Business Relief Act of This legislation extends the freeze on Medicare physician payments until Sept. 30, It also provides an extension to the therapy cap exception process through Dec. 31, 2010 and an extension of the geographic practice cost index floor through Dec. 31, Never approved by the Senate.H.R We are now on hold again…

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6 The SGR formula which has been flawed for years signals that we will have a 21.2% DECREASE in the conversion factor after 4/1/10. Physician drugs are now included in the SGR formula, allegedly skewing it upwards. CMS has eliminated Part B drugs from the SGR meaning lower future reductions. But, for right now, we are stuck with a conversion factor of $ down from $ after the 2 month hold. For 3 months, CF = $

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8 CMS has long had confusing rules relative to consults. So, the easiest way to deal with the problem is to eliminate them altogether. What this means is: New consults in the office will be coded as New Patients ( ). This means that no one in practice of your specialty has seen the patient at all for 36 months. Established consults in the office will be coded as Established Patients ( )…this is not an exact match with consultation criteria. Hospital consults will be coded as Admissions ( ) with a new modifier (“AI”) signifying who was the admitting physician. There is no exact crosswalk of five levels to three. TeleHealth consults are the exception. They have special G-codes.

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Why? Link to the Final Rule The section showing the consultation changes can begins on page

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Medicare Q&A Is CMS going to crosswalk the CPT consultation codes that are no longer recognized to the E/M codes for each setting in which an E/M service that could be described by a CPT consultation code can be furnished? No, providers must bill the E/M code (other than a CPT consultation code) that describes the service they provide in order to be paid for the E/M service furnished. The general guideline is that the provider should report the most appropriate available code to bill Medicare for services that were previously billed using the CPT consultation codes. For services that could be described by inpatient consultation CPT codes, CMS has stated that providers may bill the initial hospital care service CPT codes and the initial nursing facility care CPT codes, where those codes appropriately describe the level of service provided. When those codes do not apply, providers should bill the E/M code that most closely describes the service provided. 13 MLN Matters® Number: SE1010

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Medicare Q&A How should providers bill for services that could be described by CPT inpatient consultation codes or 99252, the lowest two of five levels of the inpatient consultation CPT codes, when the minimum key component work and/or medical necessity requirements for the initial hospital care codes through are not met? There is not an exact match of the code descriptors of the low level inpatient consultation CPT codes to those of the initial hospital care CPT codes. For example, one element of inpatient consultation CPT codes and 99252, respectively, requires “a problem focused history” and “an expanded problem focused history.” In contrast, initial hospital care CPT code requires “a detailed or comprehensive history.” Providers should consider the following two points in reporting these services. First, CMS reminds providers that CPT code may be reported for an E/M service if the requirements for billing that code, which are greater than CPT consultation codes and 99252, are met by the service furnished to the patient. Second, CMS notes that subsequent hospital care CPT codes and 99232, respectively, require a “problem-focused interval history” and “an expanded problem focused interval history” and could potentially meet the component work and medical necessity requirements to be reported for an E/M service that could be described by CPT consultation code or MLN Matters® Number: SE1010

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Medicare Q&A How will more reporting of initial hospital care CPT codes instead of CPT consultation codes affect the review of claims by Medicare contractors? CMS has alerted MAC audit staff as well as Medicare Recovery Audit Contractors of its expectation that physicians may bill more E/M codes for initial hospital care in place of billing inpatient CPT consultation codes. CMS has also alerted contractors to expect a different proportion of various initial hospital care CPT codes under the new policy. CMS expects contractors to consider that these may be appropriate changes when making decisions about whether to pursue medical review and other types of claims review. 15 MLN Matters® Number: SE1010

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Medicare Q&A Because CPT consultation codes are no longer recognized by CMS for payment, is the definition of transfer of care no longer relevant? Yes, CMS agrees that discontinuing recognition of the CPT consultation codes for payment renders the issues regarding the definition of what constitutes a transfer of care no longer relevant. 16 MLN Matters® Number: SE1010

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Medicare Q&A Can a provider provide an advance beneficiary notice (ABN) to the beneficiary and then bill his or her charge for the consultation after the consultation is billed and denied by Medicare? No, when a CPT consultation code is reported to Medicare, the claim is not denied. Instead, the claim is returned to the provider for a different CPT code because Medicare recognizes another code for payment of E/M services that may be described by CPT consultation codes. Once the claim is resubmitted to report an appropriate, payable E/M code (other than a CPT consultation code) for a medically reasonable and necessary E/M service, the beneficiary can only be billed any applicable Medicare deductible and coinsurance amounts that apply to the covered E/M service. 17 MLN Matters® Number: SE1010

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Medicare Q&A How should E/M services previously reported by CPT consultation codes and provided in a split/shared manner be billed? The split/shared rules applying to E/M services remain in effect, including those cases where services would previously have been reported by CPT consultation codes. Huh? 18 MLN Matters® Number: SE1010

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Medicare Q&A Do admitting physicians still get paid if they do not report the modifier “-AI?” Yes, the use of the modifier is for informational purposes only. 19 MLN Matters® Number: SE1010

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21 Concurrent Care “Concurrent care is provision of similar services (e.g. hospital visits) to the same patient by more than one physician on the same day. When concurrent care is provided, no special reporting is required. ” Transfer of Care “Transfer of care is the process whereby a physician who is providing management for all or some of a patient’s problems relinquishes this responsibility to another physician who EXPLICITLY agrees to accept this responsibility and, who from the initial encounter is not providing consultative services.” “Consultation codes should not be reported by the physician who has agreed to accept the transfer of care before the initial evaluation, but are appropriate to report if the decision to accept the transfer of care cannot be made until after the initial consultation…”

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22 “A consultation is a type of evaluation and management service provided by a physician at the request of another physician or appropriate source to either recommend care for a specific condition or problem or determine whether to accept responsibility for ongoing management of the patient’s entire care or for the care of a specific condition or problem.”

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23 Evaluation and Management (E/M): Consultations: To clarify the two situations under which consultations may be reported, the Evaluation and Management (E/M) section subheading, "Consultations" has been revised. These situations are: 1) to provide opinion/services for a specific condition or problem, or 2) to allow a determination to be made on whether to accept the ongoing management of the patient's entire care or for the care of a specific condition or problem (i.e. transfer of care AFTER an evaluation of the patient's problem). CPT outlined that documentation of the written or verbal request for a consultation can be done by either the consultant or by the requesting physician or other appropriate source. You may remember that Medicare requires (until January 1) that BOTH the requesting and consulting physicians document the request. But, the request DOES need to be documented.

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24 Patients and/or families cannot initiate consultations. Transfer of care definition in both office and hospital consults. All admitting E/M services are bundled into an inpatient consultation on the date of admission. Only one consult in the hospital or nursing facility stay. This includes inpatient and outpatient consultations. Documentation: Request Opinion Written report

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25 Key mechanism for transforming Medicare from passive payer to active purchaser. Current Medicare Physician Fee Schedule is based on quantity and resources consumed, NOT quality or value of services. Value = Quality / Cost Incentives can encourage higher quality and avoidance of unnecessary costs to enhance the value of care.

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PQRI quality measures for PQRI quality measures proposed so far for 2010; this includes all ways of reporting. Coding and measure specifications are available at: Read all measures before choosing.

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29 The Oncology Pain Measures (#143 and 144) will be reportable ONLY by registries. The Melanoma measures (# ) will only be reportable by Registry in CMS is moving toward Registry reporting and away from claims-based reporting. There is a new measure, “Cancer Stage Documented”-- Measure #194 for colon, breast, rectal, etc. cancer. Check it out!!!

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30 Measure Groups Report on one or more measure groups---13 measure groups Diabetes mellitus, chronic kidney disease, preventive care, coronary artery bypass graft, rheumatoid arthritis, peri-operative care, back pain, hepatitis C, heart failure, coronary artery disease, ischemic vascular disease, HIV/AIDS, community-acquired pneumonia Choose a measure group only if ALL the measures within the group are applicable to services provided to Medicare patients by the reporting provider. Review the 2010 PQRI Measures Group Specifications Manual to determine if a particular measures group is applicable for your practice

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32 Criteria for claims-based submission of individual measures (1 option): 3 PQRI measures or 1-2 measures if < 3 apply* 80% of applicable Medicare Part B FFS patient claims for 1-3 measures If < 3 measures, measures are subject to measure applicability validation (MAV) Criteria proposed for 2010 annual reporting also includes that each measure must have a minimum of 15 patients for each measure. THIS WAS NOT APPROVED IN THE FINAL RULE!

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Should You Use A Registry?? Registries are trained to process and submit data. 96% of EPs reporting by registry in 2008 were successful, which accounted for 17% of all payments. Registries save you from having to submit at the time of service by claim. Registries do cost $$$, but your time is worth $$$. This is not to represent that registries will take all of the work out of PQRI, but you will have a better handle on getting paid. It’s not too late!! Get the list--- folder/ 33

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35 EHR/EMR Reporting 10 specific individual measures, but none in Oncology Must meet these criteria if Oncology does get EMR/ EHR reporting including Be able to transmit data elements per specific CMS criteria Be able to separate out and report on CMS FFS patients only Be able to transmit TIN/NPI information Be able to transmit in approved formats Be able to transmit in a HIPAA secure format Enter into legal arrangements that permit receipt of and transmission of patient-specific data Obtain permission by NPI number Must pass CMS test. “Group Practices” may report, but only if they have 200 providers.

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36 Patient must have the right diagnosis and that must be linked to the PQRI codes. Codes must be arrayed per measure specifications. Patient must meet the age requirement. Codes must be reported with the denominator CPT or HCPCS codes. Claims must have an NPI. 80% is calculated by NPI. assn.org/ama/pub/category/17432.html Get forms at assn.org/ama/pub/category/17432.html

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The Future of PQRI Health Reform reinforced PQRI for the foreseeable future. 1% in % in ; still voluntary 2015: -1.5% for non-participation After 2015: -2.0% 37

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38 YearSuccessful**Not 20092%0% 20102%0% 20111%0% 20121%-1% %-1.5% %-2% In 2009 and 2010, physicians who successfully e-prescribe may receive a bonus payment of 2 percent of their overall Medicare reimbursement in addition to a potential 2 percent incentive related to PQRI for a potential bonus of 4 percent in Medicare reimbursement. ***No double incentives for those participating in the ARRA EMR incentive program.

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39 E-prescribing measure is reportable only through claims in 2009; in 2010, CMS proposes three methods—claims, registries, and EHRs. Limitation to applicability of incentive payment Denominator codes (E/M etc) for the e-prescribing measure must comprise at least 10% of an EP’s total allowed charges for all covered services furnished by the EP during the reporting period

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Oncology Issues Blood Transfusion Units of Service IV Hydration Units of Service Neulasta Units of Service Pump/Pump Supplies Facility versus Non-Facility SNF Billing A4221 Units of Service Global versus –TC, -TC in facility CSW During Inpatient Services to Hospice Patients “New” versus Established patients DME Charged After date of Death MUEs 49 These are changing daily—Check the Web Site often

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50 Look to see what improper payments were found by the RACs: Demonstration findings: Permanent RAC findings: will be listed on the RACs’ websites Look to see what improper payments have been found in OIG and CERT reports OIG reports: CERT reports:

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Meaningful USE--Qualifying Criteria Meeting specified HIT standards, policies, implementation specifications, timeframes, and certification requirements. CMS generally expects that under Medicare, “meaningful EHR users” would demonstrate each of the following: meaningful use of a certified EHR, the electronic exchange of health information to improve the quality of health care, and reporting on clinical quality and other measures using certified EHR technology, integrated decision support, and computerized provider order entry. Must meet 24 points before 7/1/11…many EMRs or EHRs do not meet these today. BUT, the proposal may be amended. There are three phases to this. 51

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Ambulatory Incentive Opportunities 52

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Meaningful Use Incentives for meaningful use in one of two programs (not both) Two programs proposed rules on 12/30/09 Proposed Rule: "Meaningful Use" Standards _PI.pdf Proposed Rule: Incentive Program _PI.pdf _PI.pdf _PI.pdf Medicaid or Medicare Penalty if not doing meaningful use by

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Incentives Proposed Rule 12/30/09 For the first year an EP applies for and receives an incentive payment, CMS proposes that an EHR Reporting Period is 90 days for any continuous period beginning and ending within the year. For every year after the first payment year, CMS proposes that the EHR reporting period is the entire year. A Payment Year equals a Calendar Year (CY). Incentive payments for meaningful EHR use end after A qualifying EP will receive an incentive payment equal to 75 percent of Medicare allowable charges for covered professional services furnished by the EP in a payment year, subject to maximum payments. In general, a qualifying EP can receive an annual incentive payment as high as $18,000 if their first payment year is 2011 or Otherwise, the annual incentive payment limits in the first, second, third, fourth, and fifth years are $15,000, $12,000, $8,000, $4000, and $2,000 respectively. In general, the maximum amount of total incentive payments that an EP can receive under the Medicare program is $44,000. An EP who predominantly furnishes services in a geographic Health Professional Shortage Area is eligible for a 10 percent increase in the maximum incentive payment amount. The maximum amount of total incentive payments that such an EP can receive under the Medicare program is $48,400. For EPs who begin to be meaningful EHR users in 2014, their payment calculations will be made as if they began meaningful use in (That is, if an EP were to begin meaningful use in 2014, the EP would receive $12,000 for that year, the second year’s amount as if they had begun in 2013) is the last year for which an EP can begin receiving incentive payments for meaningful use. Incentive payments for meaningful HER use ends after Maximum Total Amount of EHR Incentive Payments for a Medicare EP is outlined in the table below 54

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58 PECOS To assist providers in their quest to get physicians enrolled in PECOS, the Part B MACs will be sending revalidation letters to all physicians who have not updated their Medicare enrollment in over 6 years. (Medicare contractors first began updating the PECOS database with physician enrollments in November of 2003; therefore, physicians enrolled prior to this date will not be in the database.). The letter will instruct the physician to submit either an updated paper enrollment form or to enroll online via PECOS. Revalidation of some labs Need to update any changes within 30 days Address, phone, suite New members in group Other changes If no claims to Medicare in one year—physician is disenrolled in Medicare

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Consignment Closets Rescinded!!! CMS has issued Compliance Standards for Consignment Closets and Stock and Bill Arrangements. The purpose of Change Request 6528 was to define and prohibit certain arrangements where an enrolled supplier of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) maintains inventory at a practice location which is not owned by the enrolled DMEPOS supplier, but rather owned by a physician, non-physician practitioner or other healthcare professional, which arrangements are sometimes referred to as "consignment closets" or "stock and bill arrangements.” The CMS announcement does not prohibit these arrangements, but indicates that they must comply with the following requirements: 1.The title to the DMEPOS shall be transferred to the enrolled physician, non-physician practitioner or practice at the time the DMEPOS is furnished to the beneficiaries; 2.The physician or non-physician practitioner shall bill for the DMEPOS supplies and services using their own enrolled DMEPOS billing number; 3.All services provided to a Medicare beneficiary concerning fitting or use of the DMEPOS shall be performed by individuals being paid by the physician or non-physician practitioner's practice, and not by any other DMEPOS supplier; 4. The beneficiary shall be advised that if he or she has a problem or question regarding the DMEPOS, then the beneficiary should contact the physician or non-physician practitioner and not the DMEPOS supplier who placed the DMEPOS at the physician or non-physician practitioner's practice; and 5. The National Supplier Clearinghouse Medicare Administrative Contractor (NSC-MAC) shall verify that two or more enrolled DMEPOS suppliers shall not be enrolled and/or located at the same practice location and that each practice location shall have a separate entrance and separate post office address. 59 Should infusion pumps be an exception to this?

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Signatures: Review Criteria Auditors: MACs, CERTs, and RACs, just to name a few. CMS requires that orders for healthcare services and the services that were provided be authenticated by the author using either a handwritten or electronic signature. CMS has made it clear that stamped signatures are not an acceptable form of authentication. The previous language in the CMS Program Integrity Manual required a “legible identifier”. The recent CMS Transmittal 327 has added additional clarification and signature assessment requirements.CMS Transmittal 327 If the reason for a pre- or post-payment denial is unrelated to the signature requirement, the contracted reviewer can disregard the signature authentication process. However, if the criteria in the specific Medicare policy cannot be met because the documentation is missing a signature or it is not legible, the reviewer is instructed to proceed to the signature assessment procedure. If the signature is missing from an order, the reviewer has been instructed to disregard the order during the review of the claim. If the signature is illegible, the reviewer can request a signature log or attestation statement to determine the identity of the author of a medical record entry. Although there is not a specific attestation form at this time, the transmittal does provide specific language that should be considered if the provider is using this process. If the signature is missing from any other medical documentation, excluding the order, the reviewer should accept a signature attestation from the author of the medical record entry. Providers should not add late signatures to the medical record “beyond the short delay that occurs during the transcription process” and should instead use the signature attestation process. Other providers in the same group may not attest to the original author’s signature. In addition, if the Medicare policy is “silent” on whether a signature must be dated, the reviewer has been instructed to ensure that the rest of the documentation contains enough information to determine the date when the service was ordered and/or performed. For example, the reviewer finds that the first and third order on a page have a specific date; however, the second order on the same page is not dated. It could be assumed that the second order occurred on the same date. All providers should be reviewing all documentation for dates and signatures in a timely manner and prior to considering the medical record complete. Providers should also be reviewing all documentation prior to sending medical record copies to contractors for review. If a signature is not legible or is missing, the providers should take the appropriate steps to comply with the requirement in advance to prevent delays regarding the outcome of the review. Also, review all request letters for any additional language the reviewer might add reminding you that a signature log or attestation can be submitted with the copies as part of the Additional Documentation Request (ADR). 60

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61 Cash is the practice’s most vital resource. Make sure you have your cash requirements in mind with every decision you make. Do not live beyond your means. Remember that collections start with the referral and ends with payment. Collections also start at the top with the physicians. Patients should pay balances with every encounter. Do not get behind in your payments to distributors. This is the beginning of the end of your survival. Nobody is your friend if you owe them money. Ensure that your billing system is sophisticated enough to meet your needs. You need to keep close tabs on your production by code, your DSO, and your Accounts Receivable. This system is your lifeline. Make sure physicians are re-educated regarding the proper coding and documentation for consults and lack thereof. Check the signatures in your records for compliance. If you haven’t participated in PQRI, use a REGISTRY. Start getting prepared for “meaningful use” HIT incentives and direct submission of PQRI data. Get with your EMR vendor! Make sure you are prepared for more cash flow interruptions. Participate in the struggle! The fight is not over yet!